Nursing development unit: developing a new philosophy in the NDU

Co-creating system-wide improvement for people with traumatic brain injury across one integrated care system in the United Kingdom to initiate a transformation journey through co-production

BACKGROUND AND OBJECTIVE

There is a need for better integration of services across communities and sectors for people living with traumatic brain injury (TBI) to meet their complex needs. Building on insights gained from earlier pilot work, here we report the outcomes of a participatory workshop that sought to better understand the challenges, barriers and opportunities that currently exist within the care pathway for survivors of TBI.

METHODS

A diverse range of stakeholders from the acute and rehabilitation care pathway and the health and social care system were invited to participate in a 3-h workshop. The participants worked in four mixed subgroups using practice development methodology, which promotes person-centred, inclusive and participatory action.

RESULTS

Thematic analysis identified shared purposes and values that were used to produce a detailed implementation and impact framework for application at both the level of the care interface and the overarching integrated care system. A variety of enablers were identified that related to collective values and behaviours, case management, team leadership and integrated team working, workforce capability, evidence-based practice and resourcing. The clinical, economic, cultural and social outcomes associated with these enablers were also identified, and included patient safety, independence and well-being, reduced waiting times, re-admission rates, staff retention and professional development.

CONCLUSION

The co-produced recommendations made within the implementation and impact framework described here provide a means by which the culture and delivery of health and social care services can be better tailored to meet the needs of people living with TBI. We believe that the recommendations will help shape the formation of new services as well as the development of existing ones.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement have been established over a 10-year history of relationship building through a joint forum and events involving three charities representing people with TBI, carers, family members, clinicians, service users, researchers and commissioners, culminating in a politically supported event that identified concerns about the needs of people following TBI. These relationships formed the foundation for the interactive workshop, the focus of this publication.

Change starts with me: an impact evaluation of a multiprofessional leadership programme to support primary care networks in the South East of England

Purpose

This paper aims to present the impact evaluation findings from a multiprofessional leadership programme commissioned in the South East of England to support primary care networks (PCNs) to lead system improvement together. It identifies programme impact at micro and meso system levels; a leadership impact continuum that can be used by individuals and teams to evidence impact of improvements in PCN practices; the learning and development strategies that were effective and proposes implications for other networks.

Design/methodology/approach

Mixed methods underpinned by practice development methodology were used to explore the impact of the programme on two practitioner cohorts across 16 PCNs. Data were collected at the start, mid-point and end of the eight-month programme.

Findings

Results illustrate an innovative approach to collective leadership development. A continuum of impact created with participants offers insight into the journey of transformation, recognising that “change starts with me”. The impact framework identifies enablers, attributes and consequences for measuring and leading change at micro, meso and macro levels of the health-care system. Participants learned how to facilitate change and collaboratively solve problems through peer consulting which created a safe space for individuals to discuss workplace issues and receive multiprofessional views through action learning. These activities enabled teams to present innovative projects to commissioners for service redesign, enabling their PCN to be more effective in meeting population health needs. The authors believe that this programme may provide a model for other PCNs England and other place-based care systems internationally.

Originality/value

This study offers insight into how to enable a journey of transformation for individuals and PCN teams to enhance team effectiveness and collective leadership for system-wide transformation required by the National Health Service Long Term Plan (2019).

Contribution to Impact

Maintaining momentum in action research

BACKGROUND

Action research (AR) provides a robust platform for collaboration to develop and evaluate nursing practice. It results in several outcomes, including changes in evidence-based practice, the development of research capacity, and the evaluation and sustainability of interventions, all of which can be seen as benefits compared to other approaches. However, the methodology involves cycles of action, reflection, theory and practice, so it can be challenging to maintain momentum when engaging with teams over long periods of time.

AIM

To offer strategies for maintaining momentum when using AR in nursing research.

DISCUSSION

Three strategies for maintaining momentum when undertaking AR are covered. Theory, literature and experience of using AR in which the strategies of 'connecting as people', 'working with the context' and 'understanding the influence of the leadership team' made a considerable difference in maintaining momentum and are drawn on.

CONCLUSION

Maintaining momentum in studies that use AR can be arduous, but critical reflection enables researchers to identify and overcome the challenges that arise. Researchers undertaking AR can apply the three strategies provided or other approaches to maintain momentum during all phases of a study.

IMPLICATIONS FOR PRACTICE

Maintaining momentum in AR studies is more successful when researchers connect with those with whom they are undertaking research. It is advantageous for nurse researchers to reflect on and understand the influence of the leadership team and context rather than try to adapt them to the study's or their own needs.

Designing and implementing an electronic nursing record to support compassionate and person-centred nursing practice in an acute hospital using practice development processes

Background

The complexity of nursing practice can pose challenges to the development of an e-record that meets all the requirements and standards whilst capturing the essence of the relationship between the nurse and his/her patients.

Aims

1. Describe the process of designing the content of an electronic nursing record (e-record) specific to nursing in an Irish/UK context, using Practice Development (PD) methodology.2. To share the learning of involving the end-user in the development of a person-centred e-nursing record.

Methods

Evidence-based PD methodologies, principles and evaluation tools were employed to involve end users in the development of a person-centred and evidence-based e-record.

Results

The results are limited to evaluation of the design process and reported using the SQUIRE guidelines for reporting quality improvement. Investing in time to involve end users in the design and implementation phase resulted in satisfaction and adoption of the e-record by nurses.

Conclusions

For nurses to be satisfied with the content and process flow of an e-nursing record it needs to include the relational and non-clinical aspect of nursing practice in addition to the clinical pre-set content. Involving the end user in a meaningful way supports a positive outcome.

Implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings: a pilot RCT and feasibility study

Background

Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable.

Objectives

To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care.

Design

Pilot cluster randomised trial (CRT) and associated process and economic evaluations.

Setting

Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2).

Participants

Patients (n = 639), staff (n = 211) and visitors (n = 188).

Intervention

CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity.

Main outcome measures

Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy).

Data sources

Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities.

Results

The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study.

Limitations

Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention.

Conclusions

Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation.

Trial registration

Current Controlled Trials ISRCTN16789770.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported inChapter 2was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

Reflection on observation: A qualitative study using practice development methods to explore the experience of being a hand hygiene auditor in Australia

BACKGROUND

Within the Australian public health care system, an observation model is used to assess hand hygiene practice in health care workers, culminating in a publicly available healthcare service performance indicator. The intent of this study was for the results to inform the development of a strategy to support individual auditors and local sustainability of the hand hygiene auditing program.

METHOD

This qualitative study used a values clarification tool to gain an understanding of the experiences of hand hygiene auditors. The methodology involved qualitative interpretation of focus group discussions to identify the enablers and barriers to successful performance of the auditors' role.

RESULTS

Twenty-five participants identified congruous themes of the need for peer and managerial support, improved communication and feedback, and consideration for succession planning. There was consistency in the participants' most frequently identified significant barriers in undertaking the role.

CONCLUSION

Hand hygiene auditors take pride in their role and work toward the goal of reducing health care-associated infections by having a part to play in improving hand hygiene practices of all staff members. Important themes, barriers, and enablers were identified in this study. This research will be of interest nationally and globally, considering the dearth of published information on the experience of hand hygiene auditors. This study provides evidence of the need to support individual hand hygiene auditors.

Practice development for midwifery education: an innovative way forward

Within workplaces there can be several different cultures operating, and it is widely recognised that this occurs in health services. Midwifery and maternity care has, and continues to face many challenges as services continually change and develop to meet the needs of women and their families. To help meet these challenges a practice development initiative was undertaken within a large maternity service in Australia to improve the learning and workplace culture. This service consisted of four separate units providing care for women and their families in the antenatal, birthing, postnatal and neonatal periods. The coming together of these four units as a service began with the creation of a shared values statement which was adopted by all midwifery staff. To obtain evidence of the current workplace, observations of practice, the review of women's stories, and audits of clinical data were undertaken. Nine midwives were trained and supported to facilitate critical discussions of the data. These critical discussions, reflections and analysis of the data, led to the identification of four domains or key areas the staff prioritised for change. This led to practice development groups being formed within the maternity service, who developed collaborative and creative ways of thinking about the issues or problems identified. This paper highlights how the processes of practice development were implemented to improve one of these domains "the learning and workplace culture", especially in relation to educational information and resources for women, their families and staff. The journey began over three years ago and continues to evolve.

Development of a framework for person-centred nursing

This paper presents the development and content of a person-centred nursing framework.

BACKGROUND AND RATIONALE

Person-centred is a widely used concept in nursing and health care generally, and a range of literature articulates key components of person-centred nursing. This evidence base highlights the links between this approach and previous work on therapeutic caring.

METHODS

The framework was developed through an iterative process and involved a series of systematic steps to combine two existing conceptual frameworks derived from empirical studies. The process included the mapping of original conceptual frameworks against the person-centred nursing and caring literature, critical dialogue to develop a combined framework, and focus groups with practitioners and co-researchers in a larger person-centred nursing development and research project to test its face validity.

FINDINGS

The person-centred nursing framework comprises four constructs -prerequisites, which focus on the attributes of the nurse; the care environment, which focuses on the context in which care is delivered; person-centred processes, which focus on delivering care through a range of activities; and expected outcomes, which are the results of effective person-centred nursing. The relationship between the constructs suggests that, to deliver person-centred outcomes, account must be taken of the prerequisites and the care environment that are necessary for providing effective care through the care processes.

CONCLUSION

The framework described here has been tested in a development and research project in an acute hospital setting. Whilst there is an increasing empirical base for person-centred nursing, as yet little research has been undertaken to determine its outcomes for patients and nurses. The framework developed can be described as a mid-range theory. Further testing of the framework through empirical research is required to establish its utility for nursing practice and research.

The reality of practice development for nurses working in an inpatient service for people with severe and enduring mental health problems

Nursing practice development is a growing priority for the British National Health Service. However, the nature of practice development remains poorly articulated. Despite the growing number of papers on practice development in nursing, there is insufficient guidance in the literature for the practical day-to-day management of the role, particularly in the inpatient environment. This paper explores the tensions experienced by practitioners engaged in practice development within a service for people mainly with a diagnosis of psychosis. The entrenched culture of the environment is described, which was resistant to change therefore did not easily embrace practice development. Within such a culture it is important to balance effective management with team development and support. Although this balance is essential for positive change, it is the maintenance of the balance that often leads to the tensions experienced by practice development practitioners. The paper describes numerous tensions including the competing agendas, influencing 'hearts and minds' rather than forcing change and working where people are at. Each tension is explored alongside possible survival strategies. The material presented aims to be realistic and although it may not be generalizable to other settings and staff groups, the authors hope to stimulate debate about similar or contrasting experiences of practice development.

A clash of cultures: A&E and mental health

Accident and emergency (A&E) departments have attracted little attention from psychiatric services, with the exception of emergencies and the management of self harm. Emergency staff gravitate towards those attenders with concrete physical needs, typifying mental health attenders as low status. The aim of this project, which took place over a 12 month period, was to improve the quality of care provided to persons attending an A&E department with mental health needs, through a staff development programme. It was initiated for the generic A&E nurse with no formal training in mental health care. The programme was based on knowledge generated through a collaborative approach using an action research process. This article particularly focuses on the mindsets, values and strategies which evolved through the study. The project indicated that facets of the A&E culture such as staff values, technology, communication patterns and the environment give mental health a low status. Conflict is generated between the individual and the macro culture, dominated by the excitement of trauma care and the short-term, immediate nature of the work.